outstanding issues in medication reconciliation€¦ · 3% physiotherapy registered nurse (rn) 14%...

©2014 Institute for Safe Medication Practices Canada (ISMP Canada)

Outstanding Issues in Medication Reconciliation

Margaret Colquhoun, B.Sc.Phm., FCSHP

Project Lead, ISMP Canada

http://www.ismp-canada.org/medrec/

CSHP PPC Satellite Symposia Sponsored by Hospira Healthcare Corporation


Complimentary Online Continuing Education Module

CCCEP Accredited Available until August 22, 2014

General Practitioner,

2.97%

Other, 12.92%

Pharmacist, 83.12%

Specialist, 0.93%

LPN1%

Non‐Medical Professional

15%

Nurse Practitioner

(NP)4%

Other1%

Pharmacy Student61%

Physician Assistant

3%

Physiotherapy1%

Registered Nurse (RN)

14%

Other 12.9%

Hospital24%

Independent18%

Other9%

Retail38%

Unspecified11%

Pharmacist 83%

Family Physician

64%

General Practitioner

36%

General Practitioner – 2.9%

Rx Briefcase 20131425 participants


Thanks also to………

• Canadian Patient Safety Institute• 2005 – 2014 MedRec Intervention

MedRec 2007• Unknown – did not know what we did not know

• Systems not in place

• Measures not in place

• Studies not driving practice change


Objectives

To highlight:

• Current state

• Recent data

• Getting to where we want to be

• Leadership

• Measurement and Monitoring Quality

• Role of technology

• Role of pharmacy staff

• Updated Accreditation Canada ROPs


Tonight’s Audience

• MedRec Implementation ?

• Inpatient – Admission, Transfer, Discharge

• Ambulatory

• Model of MedRec

• Who collects BPMH – Pharmacy Staff, Nursing, Physicians?

• Use of Technology

• Using technology for MedRec process?


Current State


SurveyMay 2013


Interactive Map

Relatively few self-identified “MedRec All-Stars” who have MedRec in place across admission, transfer and discharge


Health Council of Canada Report2014

More than one quarter of Canadians said that, in the past year, a doctor or pharmacist had not explained the side-effects of the drugs they were prescribed, had

not given them a written list of their prescriptions, and/or had not reviewed all their

medications with them.

Ref: Health Council of Canada, “Where you live matters, Canadian Views on Health Care Quality”, 2014


It is still happening!!!


Recent Data


Got Med Wreck?Targeted Repairs from the Multi-Center Medication Reconciliation

Quality Improvement Study (MARQUIS)

Jeffrey L. Schnipper, MD, MPH, FHMDirector of Clinical Research, BWH Hospitalist Service

Associate Physician, Division of General Medicine, Brigham and Women’s Hospital

Associate Professor, Harvard Medical School


Review of 26 StudiesSTUDY DESIGN

• 10 RCT

• 3 Non-RCT

• 13 Pre-Post

INTERVENTIONS

• 15 Pharmacist

• 6 IT-related

• 5 “Other” = staff education, use of standardized med reconciliation tool

16

QUALITY SCORE

(Based on USPSTF Criteria)

• 6 “Good” Quality

• 5 “Fair” Quality

• 15 “Poor” Quality


Conclusions• Most robust literature is for pharmacy-

related interventions:• 15/26 studies included

• 4/6 good quality studies

• Examined clinical outcomes (ADE, utilization)

• Successful interventions included:• Intensive pharmacy staff involvement

• Focus on high risk subset of patients

17


Dr. Schnipper National Call

• Listen to the recording of this great call:

• Dr. Schnipper call


Slide Courtesy of Dr.Jeff SchnipperSafer Healthcare Now! Webinar Jan, 2014


Pennsylvania Patient Safety Advisory -2013

• 501 reports involving MedRec breakdowns in 1 year

• 69% at admission

• Events most often at prescribing (40%)

• Drug omission most frequent (26.7%)

REF: Breakdowns in the Medication Reconciliation Process, Pa Patient Saf Advis 2013 Dec;10(4):125-36.


• Prospective, randomized pilot study

• Effects of phmy clinic visit focused on MedRec after discharge on readmsissions and ED visits

• Of 61 pts 54% had discrepancies at discharge; 50% resolved in Phm. arm of study vs 9.5% in usual care arm

• Significantly lower rates of 30 day readmits and ED visits


Objectives

To review:

• “Current state” in Canada

• Recent data


• Leadership






“Senior leadership commitment is critical to ensuring MedRec is implemented successfully across an

organization. Accountability must rest with the CEO with clear

reporting expectations at the board level.”REF: Optimizing Medication Safety at Care Transitions: A National Challenge, 2011

http://www.ismp-canada.org/download/MedRec/MedRec_National_summitreport_Feb_2011_EN.pdf

LEADERSHIP ACCOUNTABILITY

Stories from Safer Healthcare Now tell us that THIS IS TRUE!!!!!


McGill – Moxxi Project

RightRx uses this “real-time” linkage to the Quebec health insurance agency (Régie de l’assurance maladie du Québec: RAMQ) to retrieve information on community medications and medical services.


Time and Motion Study McGill

• Workflow inefficiencies

• Lack of coordination, specialized training, agreement on roles, possible variability in quality and time required

• Standardization and use of electronic tools could improve efficiency


Objectives

To review:


• Recent data


• Leadership






• Effective January 2014 Accreditation Canada’s MedRec Required Organizational Practices (ROP) includes a test for compliance in which organizations are required to monitor compliance with their medication reconciliation process, and make necessary improvements.

The audit tool is a user friendly method for meeting this ROP.

(More info at: http://www.accreditation.ca/uploadedFiles/News_and_Publications/Publications/ROP_Handbook/SupplementROP-06-2013_en.pdf


National MedRec Quality

Audit Tool(for use at

Admission for Acute and LTC)


• A review of published articles found that 10-67% of patients had at least 1 prescription medication history error• when non-prescription medications were included the

frequency of errors was 25-83%• Authors suggest: “should be a comprehensive medication

history that includes an interview, inspection of medication vials or lists, or both and contact with community pharmacies, or family physicians.”

CMAJ, 2005 http://www.cmaj.ca/content/173/5/510.full.pdf+html

Literature suggests…..


Literature suggests… • 66% of Canadians have sometimes used non-prescription

medication in the past six months. • 57% sometimes took vitamins and minerals, while 34% sometimes

took herbal and natural products.2004 Survey of Canadians’ Use of OTC Medications http://www.bemedwise.ca/english/usagesurvey.html

• Adherence- “the extent to which a person’s behavior [in] taking medication…corresponds with agreed recommendations from a health care provider” (World Health Organization, 2003).

• 12% of patients don’t fill their prescription at all.• 12% of patients don’t take medication at all after they fill the

prescription.• 22% of patients take less of the medication than is prescribed on

the label. Adult Meducation http://www.adultmeducation.com/OverviewofMedicationAdherence_2.html


Literature suggests….

• Medication discrepancy was defined as a difference between the medication use history (BPMH) and the admission medication orders.

• In the sample of patients admitted to general medicine unit:

• 54% of patients had at least one unintentional discrepancy identified (most common type was omission of a regularly used medication)

• 38% of these discrepancies were judged to have the potential to cause moderate to severe discomfort or clinical deterioration


October 2013 was National MedRec Quality Audit Month

2340patients

29%(acute care)

55% (Long Term Care)

• 1906 Acute Care

• 329 Long Term Care

• Met all 5 quality criteria

• Met all 5 quality criteria

103Organizations


Results Summary Comments• Need to critically evaluate admission processes to

ensure quality of MedRec processes at other transitions

• However, audit tool results demonstrate need for ongoing and specific improvements

• Many people believe they are doing MedRec but they may not be doing it well

• The foundation of the process – the BPMH needs work


Objectives

To review:


• Recent data


• Leadership






eMedRec in Canada

Paper to Electronic Project Online Survey*

*Response rate = 212


“if you don’t use the right paper to electronic system you will increase

medication errors”

Dr. Jeffrey Schnipper, MD, MPH, FHM “Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation

Quality Improvement Study (MARQUIS)” January 14, 2014


Motivation for Moving to eMedRec

• Integrates electronic data from multiple sources ( electronic and non-electronic)

• Provides electronic tools and user interfaces for comparing medication lists

• Facilitate discharge MedRec with multiple sources of information


Recommendations

• Understand current workflow before implementing

• Understand how eMedRec can integrate with existing and planned health information system infrastructure

• Obtain management and financial support (including ongoing for sustainability)

• Need to carefully stage eMedRec implementation


Tools/Checklists• Organizational Readiness

• Steps to support the safe transition to eMedRec

• Ideal features of eMedRec,

• Evaluation of eMedRec


Objectives

To review:


• Recent data


• Leadership






INTER-PROFESSIONAL ENGAGEMENT


Evidence-Derived Clinical Pharmacy Key Performance Indicator Critical Activity Areas

(Doucette 8)

• Best Possible Medication History

• Admission Medication Reconciliation

• Patient Care Rounds

• Pharmaceutical Care

• Disease or Drug-Specific Quality Indicators

• Patient Education/Discharge Counseling

• Discharge Medication Reconciliation

• Post-Discharge Follow-Up


• 198 medication discrepancies were identified (mean 2.6 per patient)• 15% of the discrepancies

were deemed potentially serious or fatal

• 62% were potentially significant

• 23% were potentially non-significant

• 129 drug-related problems were identified by medication review (mean 1.7 per patient)• 35% were potentially

serious or fatal• 29% were potentially

significant• 36% were potentially

non-significant

Retrospective review of 75 patient charts found:


Role of the pharmacy technician


Slide Courtesy of Dr.Jeff SchnipperSafer Healthcare Now! Webinar Jan, 2014


Undergraduate Healthcare Practitioner Education


Objectives

To review:


• Recent data


• Leadership






Accreditation Canada ROP Changes for 2014

For services that use standards that contain an applicable MedRec ROP:• For on-site surveys between 2014-2017,

MedRec must be implemented across admission, transfer and discharge in ONE service

• For surveys 2018 onwards, MedRec must be implemented across admission, transfer and discharge in ALL services

http://www.accreditation.ca/sites/default/files/rop-handbook-2014-en.pdf


Accreditation Canada ROPsChanges in 2015

Inclusion of MedRec in Emergency Department for NON-ADMITTED patients


To Review: Objectives


• Recent data


• Leadership



• Role of pharmacy staff• Updated Accreditation Canada ROPs

outstanding issues in medication reconciliation€¦ · 3% physiotherapy registered nurse (rn) 14%...

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